SHOULDER ASSESSMENT

AYESHA RAZZAQ
BONES OF THE SHOULDER

Image from [Link]

MUSCLES, TENDONS, LIGAMENTS
SCAPULOHUMERAL RHYTHM
 Motion of the scapula, synchronous with motions of the
humerus, allows for 150 to 180 of shoulder ROM into
flexion or abduction with elevation. The ratio has
considerable variation among individuals but is
commonly accepted to be 2:1 (2 of glenohumeral
motion to 1 of scapular rotation) overall motion. During
the setting phase (0 to 30 abduction, 0 to 60 flexion),
motion is primarily at the glenohumeral joint, whereas
the scapula seeks a stable position. During the mid-
range of humeral motion, the scapula has greater
motion, approaching a 1:1 ratio with the humerus; later
in the range, the glenohumeral joint again dominates
the motion.
COMMON SOURCES OF REFERRED
PAIN IN THE SHOULDER REGION
 Cervical Spine
 Vertebral joints between C3 and C4 or between C4
 and C5
 Nerve roots C4 or C5
 Referred Pain from Related Tissues
 Dermatome C4 is over the trapezius to the tip of the
 shoulder.
 Dermatome C5 is over the deltoid region and lateral
 arm.
 Diaphragm: pain perceived in the upper trapezius
 region.
 Heart: pain perceived in the axilla and left pectoral
 region.
 Gallbladder irritation: pain perceived at the tip of shoulder
 and posterior scapular region.
NERVE DISORDERS IN THE SHOULDER GIRDLE
REGION

 Brachial plexus in the thoracic outlet.

 Common sites for compression are the scalene triangle,
costoclavicular space and under the coracoid process,
and pectoralis minor muscle.
 Suprascapular nerve in the suprascapular notch.
 This injury occurs from direct compression or from
nerve stretch, such as when carrying a heavy book bag
over the shoulder.
 Radial nerve in the axilla.
 Compression occurs from continual pressure, such as
when leaning on axillary crutches
SHOULDER PAIN: WHERE TO START?
 Shoulder history & exam (GP/physio/shoulder specialist)

 Diagnosis
 Xrays are often very helpful
 MRI is not always the first thing to do!
In some cases, you may never need an MRI or you may need a
different type of scan (CT etc.)

 Plan
 Further imaging to complete diagnosis
 Anti-inflammatory medication
 Physiotherapy
 Injections
 Surgery
SHOULDER PROBLEMS IN OVER 50S
 Rotator cuff disease (tendinitis, tears)

 Shoulder Arthritis

 AC Joint Arthritis

 Frozen shoulder

 Fractures
ROTATOR CUFF DISEASE
ROTATOR CUFF DISEASE
 Group of 4 muscles around the shoulder joint

 Function in shoulder joint stability and contribute to certain movements

 The tendons often degenerate over time

 Partial tears

 Tendinitis

 Impingement

 Full thickness tears

 MRI may be appropriate if rotator cuff weakness is found on clinical

exam
GLENOHUMERAL JOINT ARTHRITIS
 The following characteristics are associated with
glenohumeral (GH) joint pathologies that lead to
hypomobility.
 Acute phase. Pain and muscle guarding limit motion,
usually external rotation and abduction. Pain is
frequently experienced radiating below the elbow and
may disturb sleep. Joint swelling is not detected owing
to the depth of the capsule, although tenderness can
be elicited by palpating below the edge of the
acromion process between the attachments of the
anterior and middle deltoid.
 Subacute phase. Capsular tightness begins to develop. Limited
motion is detected, consistent with a capsular pattern (external
rotation and abduction are most limited, and internal rotation and
flexion are least limited). Often, the patient feels pain as the end of
the limited range is reached. Joint-play testing reveals limited joint
play. If the patient can be treated as the acute condition begins to
subside by gradually increasing shoulder motion and activity, the
complication of joint and soft tissue contractures can usually be
minimized.
 Chronic phase. Progressive restriction of the GH joint capsule
magnifies the signs of limited motion in a capsular pattern and
decreased joint play. There is significant loss of function with an
inability to reach overhead, outward, or behind the back. Aching is
usually localized to the deltoid region.
SHOULDER ARTHRITIS
AC (ACROMIOCLAVICULAR) JOINT
FROZEN SHOULDER
IDIOPATHIC FROZEN SHOULDER
 This clinical entity follows a classic pattern*.
 “Freezing.”
 Characterized by intense pain even at rest and limitation of motion by 2 to 3
weeks after onset. These acute symptoms may last 10 to 36 weeks.
 “Frozen.”
 Characterized by pain only with movement,significant adhesions, and
limited GH motions, with substitute motions in the scapula. Atrophy of the
deltoid, rotator cuff, biceps, and triceps brachii muscles occurs.
 This stage lasts 4 to 12 months.
 “Thawing.”
 Characterized by no pain and no synovitis but significant capsular
restrictions from adhesions. This stage lasts 2 to 24 months or longer. Some
patients never regain normal ROM.
FROZEN SHOULDER
 Most cases will resolve without surgery
 The inflammatory process “burns itself out”
 Freezing, frozen, thawing stages
 Pain and discomfort can be severe, therefore attempts are
made to shorten the process
 Steroids
 Tablets in some cases
 Injections
 Some patients go on to need surgical release of the capsule
and manipulation of the shoulder under anaesthesia
 Gentle physiotherapy
 Pool exercises
FROZEN SHOULDER
SHOULDER FRACTURES
SHOULDER FRACTURES

 Not all shoulder fractures

need to be fixed

 Important to have a
specialist opinion early,
in order to decide if any
surgery is needed
CLINICAL EXAMINATION
BILATERAL SHOULDER FLEXION

 Examining bilateral shoulder flexion is beneficial in determining symmetry of

movement and assessing scapulohumeral rhythm. Symmetrical movement
requires a balance of active muscular control and compliance of passive
[Link] primary contributors to symmetrical movement include the
force-coupled movements of the rotator cuff at the glenohumeral joint, and
the force-coupled control of the serratus anterior and appropriate
stabilization and movement contributions from the trapezius for the
scapulothoracic joint. Pain intensity is important to identify during active
movement because pain has been shown to inhibit the contribution of the
serratus anterior and the lower fibers of the trapezius. With inhibition of
these two critical muscles, movements near and above 90 degrees of
elevation are significantly altered. The scapula should move congruently
with the thorax, with slight internal rotation and a medial glide.34 Pain
might cause abnormal scapular elevation, lateral translation, and AC joint
separation. The patient should stand in the targeted posture (typically
standing). The patient is requested to raise both arms together. The
clinician should carefully evaluate movement for symmetry and appropriate
sequencing. The patient is requested to lower both arms together, the
clinician carefully evaluating movement for symmetry and appropriate
sequencing.
UNILATERAL SHOULDER FLEXION

 With active range of movements, the noninvolved

shoulder is evaluated first. The patient should stand and
raise his or her arm to the first point of pain (if present).
Movement height and quality are evaluated. The patient
is requested to raise the arm past the first point of pain
(if present) toward end range. Pain is again evaluated
and compared to the initial point of pain. The patient is
then requested to perform repeated movements near
the end range to determine the behavior of the pain. If
no pain was reproduced during the movement, an
overpressure is performed to the patient. The motion is
repeated on the other side.
BILATERAL SHOULDER ABDUCTION

 Bilateral shoulder abduction is beneficial to analyze. As with shoulder

flexion, the appropriate force-coupled contractions of the shoulder
musculature are required for symmetry and stability. One common
problem seen during pain and/or rotator cuff dysfunction is the rapid
dropping of the arm during 70–110 degrees of shoulder abduction.
At this position, control of the drop of the humerus requires use of a
strong eccentric contraction and if weakness or pain is present
during this position the arm will rapidly drop. The patient should
stand in the targeted posture. The patient is requested to raise both
arms together. The clinician should carefully evaluate movement for
symmetry and appropriate sequencing. The patient is requested to
lower both arms together. The clinician should carefully evaluate
movement for symmetry and appropriate sequencing
EXTENSION

 Isolated active extension is an effective method to determine

the passive mobility of the biceps tendon and may be useful
in determining if the humerus has shifted anteriorly in the
joint cavity (range will be limited and pain will be located
anteriorly at the shoulder). The patient stands in the targeted
posture and baseline symptoms are evaluated. The patient
is requested to move his or her arm backward to the first
point of pain (if present). Movement distance and quality are
evaluated. The patient is requested to move beyond the first
point of pain near end range with repeated movements. If no
pain is present, an overpressure is applied to clear the
movement. The complete procedure is repeated on the
opposite side.
HORIZONTAL ADDUCTION

 Isolated horizontal adduction is an effective movement to

test the flexibility of the posterior capsule. To engage the
posterior capsule further, internal rotation can be added as a
combined movement. The patient stands in the targeted
posture and baseline symptoms are evaluated. The patient
is requested to move his or her arm across the body in an
attempt to place the hand on the opposite shoulder. The
patient is instructed to identify the first point of pain (if
present) and movement distance and quality are evaluated.
The patient is requested to move beyond the first point of
pain near end range with repeated movements. If no pain is
present an overpressure is applied to clear the joint. The
complete procedure is repeated on the opposite side.
BILATERAL EXTERNAL ROTATION

 Bilateral external rotation at 90 degrees of abduction places

a greater stress on the inferior capsular structures than an
external rotation movement with the arm placed at the
side.35 It may be conducive to measure external rotation in
both positions (at 90 degrees and at 0 degrees at the side),
although a passive physiological assessment will provide
more specific information as to the position of the
impairment. The patient stands in the targeted posture.
Baseline symptoms are evaluated. The patient is directed to
raise both arms and lace the hands behind the head. If no
pain is present during the movements, the patient may
require overpressure, which is applied by gently pulling back
on the elbows while behind the patient. Overpressure can
occur to one or both arms at the same time.
GLENOHUMERAL POSTERIOR ANTERIOR (PA)
GLIDE

 A PA glide in a loose-packed position may not

be helpful in improving range of motion for
restricted abduction and/or external [Link]
glide is equally effective for improving
abduction as an AP when the humerus is
placed in an end-range position. PA glide does
lead to neurophysiological changes, including
increased conductivity for the complete upper
limb.
 PA for Pain Control
 The patient is placed in supine and their hands are draped across their
stomach. The clinician uses both thumbs to contact the posterior aspect of
the humeral head of the patient, whereas the fingers rest gently on the
anterior surface of the patient’s shoulder. Using the side of the plinth as a
lever, the clinician gently applies a force posterior to anterior first, then pulls
downward on the humeral head to reposition the shoulder. This technique is
performed well within the tolerance of the patient and is repeated a number
of times in order to incorporate pain reduction.
 PA for Range-of-Motion Gains
 The patient is placed in prone and resting symptoms are assessed. The
clinician uses the palm of his or her hand to contact the posterior aspect of
the shoulder. To enhance the vigor of the mobilization the shoulder can be
elevated (flexion or abduction) to the concordant limit of the patient. Then,
the clinician performs a PA mobilization at the range limitation of the
patient. The use of external or internal rotation prepositioning furthers the
effect of the end-range mobilization.
GLENOHUMERAL ANTERIOR–POSTERIOR (AP)
GLIDE
 An AP glide in a loose-packed position may not be helpful in improving range
of motion for abduction and/or internal rotation, specifically if internal
rotation is limited toward the end of normal available range.51 In a neutral
position the middle posterior capsule limits AP translation whereas in a
preposition of abduction, the middle and inferior posterior capsule limits
movement. Mobilization, designed to improve shoulder flexion or abduction,
is most appropriately performed at end range,and since the majority of
shoulder pathologies lead to anterior migration of the humeral head, an
anterior to posterior glide may be the best selection. Conroy and Hayes
performed mobilizations at mid-range and theorized the lack of benefit may
be associated with the inability to engage the capsule appropriately while in
a loose-packed position. The patient is placed in supine and resting
symptoms are assessed. The clinician glides the patient’s shoulder to the
first point of pain. If pain occurs before the onset of stiffness, the
mobilization should be performed at that range using less intense force. If
stiffness is encountered concurrently or before pain, a more aggressive
mobilization at that range or in preposition of shoulder flexion or abduction
is beneficial.
GLENOHUMERAL SHOULDER TRACTION

 A glenohumeral shoulder traction technique has not shown

to lead to joint separation with the arm placed at the side
near the loose-packed position or during a close-packed
position. Subsequently, a traction-based mobilization will
primarily demonstrate neurophysiological benefits,
specifically useful for patients with pain as the primary
disorder. The patient is placed in supine and resting
symptoms are assessed. The clinician may use his or her
forearm to stabilize the anterior aspect of the shoulder.
Placing the patient’s forearm in pronation helps concentrate
the traction force to the shoulder. The clinician moves the
patient’s shoulder to the first point of pain by performing a
long axis distraction force. The appropriate response of the
mobilization is pain reduction
GLENOHUMERAL INFERIOR
(CAUDAL) GLIDE
The techniques used in the study were effective for abduction
mobility gains and were more effective than similar
mobilization performed at 40 degrees of abduction (non–end
range). With the patient in a supine position the clinician
prepositions the shoulder in neutral or slight abduction. The
clinician then glides the humeral head inferiorly to the first
point of pain. If pain occurs before the onset of stiffness, the
mobilization should be performed at that range using less
intense force. If stiffness is encountered concurrently or before
pain, or if the pain of the patient only occurs at mid- or end-
range abduction, an aggressive mobilization at those ranges is
beneficial . Upon completion, the clinician should reassess the
movement restriction of the patient.
ACROMIOCLAVICULAR PA GLIDE

 The acromioclavicular joint translates posterior to

anterior during scapular retraction. To perform a similar
movement of posterior to anterior translation, the
patient should be placed in a supine position. The
clinician places his or her thumb in the posterior “V”
notch (just posterior to the medial aspect of the AC
joint). The contact point of the thumbs is on the
posterior clavicle. The clinician applies a PA glide to the
AC. in an attempt to reproduce symptoms. If concordant,
the clinician may apply treatment using this technique
and can adjust the position of the scapular to sensitize
the movement.
ACROMIOCLAVICULAR INFERIOR GLIDE

 The clavicle moves inferiorly on the scapular (acromion)

contact during arm elevation. To perform a similar
assessment technique, the patient assumes a supine
position. For inferior glide, the clinician places his or her
thumb on the superior surface just medial to the AC joint
(clavicular contact). The clinician applies an inferior glide to
the AC in an attempt to reproduce symptoms. If concordant,
the clinician may apply treatment using this technique, and
can adjust the position of the scapula by moving the arm into
flexion or abduction to further sensitize the movement. The
patient who responds best to this assessment/treatment is
one that encounters pain only during end ranges of
movements that are across the body or over his or her head.
SPECIA TEST
APLEY’S SCRATCH TEST

 Apley’s Scratch Test is useful in assessing functional shoulder range

of motion in the combined movements of abduction and external
rotation and abduction and internal rotation.36 The test is functional
because the movements are required during daily activities such as
donning and doffing shirts and undergarments, combing the hair,
and hygiene activities. To assess this sequence of movements, the
patient stands in the targeted posture. Starting with the uninvolved
side first, the patient is instructed to reach behind his or her head
and touch as low as possible on the spine. The patient is then
instructed to reach behind his or her back and reach the same
aspect of the opposite shoulder blade now moving with the involved
side. The patient is prompted to try and touch the fingers of both
hands during the combined movements of abduction and external
rotation with one arm and adduction and internal rotation of the
other
TREATMENT OPTIONS
 Physiotherapy

 Injections with local anaesthetic and corticosteroid

(anti-inflammatory effect)

 Surgery
 Arthroscopic subacromial decompression
 Rotator Cuff Repair
 Reverse Shoulder Replacement
SUMMARY
 There are many potential causes of shoulder pain and
dysfunction

 There are many ways to treat these problems

 History & Exam – Diagnosis – Treatment Plan

 MRI is not always required

 Non-surgical options exist for some problems

 Shoulder surgeries vary in terms of post-op rehab

REFERENCES
 Bankart, Arthur Sidney. "The pathology and
treatment of recurrent dislocation of the
shoulder‐joint." British Journal of Surgery 26.101
(1938): 23-29.
 Inman, Verne T., and LeRoy C. Abbott.
"Observations on the function of the shoulder
joint." JBJS 26.1 (1944): 1-30.
 Bankart, AS Blundell. "Recurrent or habitual
dislocation of the shoulder-joint." British medical
journal 2.3285 (1923): 1132.